HospitalInspections.org

Reference NFPA 72 National Fire and Signaling Code (2010 Edition)

14.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.


Based on record review and interview, the facility failed to ensure smoke detectors were tested for sensitivity at least every two years as required by NFPA 72 (National Fire Alarm Code). Without this testing, the facility has no assurance the smoke detectors would detect smoke within their listed sensitivity, which in the event of fire, which presents the risk of potential harm by fire to all patients, staff and visitors of the facility. The findings are:


A. Record review revealed no evidence the smoke detectors were being tested for sensitivity.

B. On 06/22/21 at 8:00 am, during interview, the Plant Services Director stated the fire alarm servicing company conducts a functional test for the smoke detectors but he hasn't seen any record indicating that sensitivity testing has been conducted in the past 2 years.

C. No further records were available for review.

Reference NFPA 25:

Chapter 15 Impairments
15.1 General.
15.1.1 Minimum Requirements.
15.1.1.1 This chapter shall provide the minimum requirements for a water-based fire protection system impairment program.
15.1.1.2 Measures shall be taken during the impairment to ensure that increased risks are minimized and the duration of the impairment is limited.
15.2 Impairment Coordinator.
15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator.
15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.
15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.
15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have
been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.


Based on observation and interview, the facility failed to ensure an impairment program was in place for the water based fire protection sprinkler system as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). It is essential an impairment program is established to ensure measures are taken during any impairments, including preplanned and emergency impairments, to the fire sprinkler system and to ensure increased risks are minimized and the duration of the impairment is limited. This deficient practice presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the fire watch log revealed a fire policy and procedure is in place when the fire sprinkler is down. However, the policy does not cover all items required per NFPA 25 such as tagging out the system, preplanned impairments, emergency impairments, and restoring the system to service.

B. On 06/22/21 at 10:30 am, during interview, the Plant Services Manager stated he has a fire watch policy available but not a full impairment program.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on the first and second nursing shifts to ensure preparedness for emergency response (Federal regulations require fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice could likely result in staff not being prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the fire drill log indicated the facility had two (2) nursing shifts:

Day Shift (7:00 am - 7:00 pm)
Night Shift (7:00 pm - 7:00 am)

B. Record review of the fire drill log revealed a fire drill was conducted on 07/29/20 at 4:30 pm on the day shift. The next fire drill on this shift wasn't conducted until 12/30/21, which exceeds the 90-day requirement.

C. On 06/22/21 at 11:45 am, during interview, the Plant Services Director stated he was unaware he exceeded the time frame between fire drills on the day shift.

D. No further records were available for review.

Based on observation and interview, the facility failed to ensure portable space heating devices were not used in patient areas, which the Authority Having Jurisdiction (AHJ) defines as within the same smoke compartment as patient areas (i.e. physical therapy areas, sleeping rooms, activity rooms, day rooms, etc). Portable space heating devices can cause fires when they malfunction due to improper use, which presents a risk of potential harm those patients that utilize Therapy Services. The findings are:

A. On 06/23/21 at 7:48 am, during observation, an electric space heater was observed in Therapy Services area. The Therapy Services area is not considered a staff only area. This area also opens directly into an egress corridor.

B. On 06/23/21 at 7:50 am, during interview, the Plant Services Director stated he didn't realize the portable heating unit was being used in the area. He stated staff may not have known about the requirement.